Case report
Ischemic rupture of the anterolateral papillary muscle
Rutura isquémica do músculo papilar ântero-lateral
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Note the extensive positive remodeling with several aneurysms in the non-stented proximal right coronary artery reference segments (B and D). Suboptimal reperfusion and no-reflow phenomenon after thrombus aspiration, multiple balloon dilations, administration of intracoronary platelet glycoprotein IIb/IIIa receptor inhibitors and adenosine, right ventricular endocavitary pacing and intra-aortic balloon pump counterpulsation (C and D).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Miguel Silva Vieira, André Luz, Diana Anjo, Nuno Antunes, Mário Santos, Henrique Carvalho, Severo Torres" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Miguel Silva" "apellidos" => "Vieira" ] 1 => array:2 [ "nombre" => "André" "apellidos" => "Luz" ] 2 => array:2 [ "nombre" => "Diana" "apellidos" => "Anjo" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Antunes" ] 4 => array:2 [ "nombre" => "Mário" "apellidos" => "Santos" ] 5 => array:2 [ "nombre" => "Henrique" "apellidos" => "Carvalho" ] 6 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000243?idApp=UINPBA00004E" "url" => "/08702551/0000003200000003/v1_201308021313/S0870255113000243/v1_201308021313/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0870255113000267" "issn" => "08702551" "doi" => "10.1016/j.repc.2012.05.027" "estado" => "S300" "fechaPublicacion" => "2013-03-01" "aid" => "242" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:239-42" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7544 "formatos" => array:3 [ "EPUB" => 175 "HTML" => 6330 "PDF" => 1039 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Understanding cardiac myxoma recurrence: A case report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "239" "paginaFinal" => "242" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Compreender a recorrência dos mixomas cardíacos – Um caso clínico" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 552 "Ancho" => 1300 "Tamanyo" => 91632 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography study with color Doppler showing the rich vascularization of the mass (A) and of the residual atrial septum (B). *: right atrial mass; AS: atrial septum; RA: right atrium.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria Salomé Carvalho, Maria João Andrade, João Abecasis, Rosa Gouveia, Luísa Branco, José Pedro Neves, Miguel Mendes" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Maria Salomé" "apellidos" => "Carvalho" ] 1 => array:2 [ "nombre" => "Maria João" "apellidos" => "Andrade" ] 2 => array:2 [ "nombre" => "João" "apellidos" => "Abecasis" ] 3 => array:2 [ "nombre" => "Rosa" "apellidos" => "Gouveia" ] 4 => array:2 [ "nombre" => "Luísa" "apellidos" => "Branco" ] 5 => array:2 [ "nombre" => "José Pedro" "apellidos" => "Neves" ] 6 => array:2 [ "nombre" => "Miguel" "apellidos" => "Mendes" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000267?idApp=UINPBA00004E" "url" => "/08702551/0000003200000003/v1_201308021313/S0870255113000267/v1_201308021313/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Ischemic rupture of the anterolateral papillary muscle" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "243" "paginaFinal" => "246" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Catarina Vieira, António Gaspar, Miguel Álvares Pereira, Nuno Salomé, Jorge Almeida, Mário Jorge Amorim" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Catarina" "apellidos" => "Vieira" "email" => array:1 [ 0 => "cfvieira1982@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "António" "apellidos" => "Gaspar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Miguel" "apellidos" => "Álvares Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Nuno" "apellidos" => "Salomé" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Jorge" "apellidos" => "Almeida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Mário Jorge" "apellidos" => "Amorim" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Cardiology, Hospital de Braga, Braga, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Cardiothoracic Surgery, Hospital de São João, Oporto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Rutura isquémica do músculo papilar ântero-lateral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1065 "Ancho" => 1500 "Tamanyo" => 167645 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional transesophageal echocardiogram showing severe mitral regurgitation caused by posterior leaflet prolapse. LA: left atrium; LV: left ventricle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Papillary muscle rupture is an infrequent but often catastrophic mechanical complication of acute myocardial infarction (MI) accounting for approximately 5% of early deaths.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The condition may result in acute mitral regurgitation, acute pulmonary edema, and/or cardiogenic shock.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Despite high operative mortality, surgery is indicated as survival of medically treated patients is very low.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report an uncommon presentation of an anterolateral papillary muscle rupture successfully repaired by surgical reimplantation of one of the papillary muscle heads.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 59-year-old man was admitted to the emergency room with acute chest pain. The 12-lead ECG (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) showed ST elevation in the inferior leads, R<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>S in V1 and ST depression in the anterior leads. The patient was hemodynamically stable and cardiac and pulmonary auscultations were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Coronary angiography showed obstruction of the proximal segment of the first obtuse marginal and significant stenosis (80%) of the proximal segment of the anterior descending artery. Primary coronary angioplasty of the first obtuse marginal and implantation of a drug-eluting stent were performed. Twelve hours later the patient suddenly became hypotensive and tachycardic. Physical examination revealed a new 3/6 holosystolic murmur at the apex and significant bilateral rales. Transthoracic echocardiography showed severe mitral regurgitation due to posterior mitral leaflet prolapse and an image of a mass in the left ventricle, which did not prolapse totally into the left atrium during systole, suggestive of an anterolateral papillary muscle head. Left ventricular size and function were relatively normal but the posterior and inferior walls were hypokinetic. Moderate tricuspid regurgitation was noticed and pulmonary artery systolic pressure was estimated at 60 mmHg.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient became oliguric, with deterioration of renal function, and so an intra-aortic balloon was placed and he was transferred to a cardiothoracic department for emergency surgery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Intraoperative 2D/3D transesophageal echocardiography confirmed rupture of one of the heads of the anterolateral papillary muscle, leading to extensive prolapse of the P1 and P2 segments and causing severe mitral regurgitation (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>A and B; <a class="elsevierStyleCrossRef" href="#sec0050">videos 1, 2 and 3</a>). On surgical inspection, it was observed that the detached muscle head (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>) had become trapped in the left ventricle by a secondary cord attached to the other head. Papillary muscle head reimplantation, mitral annuloplasty with a rigid ring, tricuspid annuloplasty with a Sovering ring and double coronary artery bypass grafting (CABG) (left internal mammary artery to first obtuse marginal and right internal thoracic artery to anterior descending artery) were performed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The postoperative period was complicated by nosocomial pneumonia but the patient recovered fully and was discharged home on the 18th day. Transthoracic echocardiography performed 15 days after surgery showed preserved global left ventricular function and mild mitral regurgitation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The posteromedial papillary muscle is supplied with blood from the posterior descending artery, while the anterolateral papillary muscle has a dual blood supply, from the left anterior descending and left circumflex arteries.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> This difference in blood supply explains why rupture of the posteromedial papillary muscle is 6–12 times more common. On the other hand, rupture of the anterolateral papillary muscle is usually associated with anterolateral MI, rarely occurring in the context of inferior MI, as happened in the case presented.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography is useful in the diagnosis of papillary muscle rupture, with a sensitivity of 65–85%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> A flail segment of the mitral valve and a severed papillary muscle or chorda can frequently be seen moving freely within the left ventricular cavity. However, in some cases, transthoracic echocardiography is not informative and transesophageal echocardiography is required to establish the diagnosis; this is most likely to occur when the ruptured head does not prolapse into the left atrium, as was observed in our patient, a feature reported in up to 35% of cases.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Emergency surgical intervention remains the treatment of choice for papillary muscle rupture. Surgery involves significant operative mortality (18%), but there are recent trends for lower operative risk, particularly with associated CABG (8.7%).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Long-term outcome after surgery is the same as that of similar MI without papillary muscle rupture.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> These encouraging observations emphasize the importance of prompt diagnosis and an aggressive therapeutic approach for patients suffering papillary muscle rupture after MI.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This case is unusual in presenting two uncommon features of ischemic papillary muscle: rupture of the anterolateral muscle in MI involving the inferoposterior walls, and the fact that the ruptured muscle head did not prolapse because it had become trapped in the left ventricle by a cord attachment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres250650" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec238218" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres250651" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec238217" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-05-25" "fechaAceptado" => "2012-06-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec238218" "palabras" => array:4 [ 0 => "Papillary muscle" 1 => "Rupture" 2 => "Surgical reimplantation" 3 => "Echocardiography" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec238217" "palabras" => array:4 [ 0 => "Músculo papilar" 1 => "Rutura" 2 => "Reimplantação cirúrgica" 3 => "Ecocardiograma" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe the case of a 59-year-old man who presented with chest pain and ST-segment elevation in the inferior leads, R<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>S in V1 and ST depression in the anterior leads due to proximal occlusion of the first obtuse marginal. Primary coronary angioplasty and stenting of this artery were performed. Twelve hours later the patient became hemodynamically unstable and severe mitral regurgitation due to rupture of one of the heads of the anterolateral papillary muscle was diagnosed. Emergency surgery was performed (papillary muscle head reimplantation, mitral annuloplasty with a rigid ring, tricuspid annuloplasty and coronary artery bypass grafting). On surgical inspection, it was observed that the detached muscle head had become trapped in the left ventricle by a secondary cord attached to the other head.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This case is unusual in presenting two uncommon features of ischemic papillary muscle: rupture of the anterolateral muscle in myocardial infarction involving the inferoposterior walls, and the fact that the ruptured muscle head did not prolapse because it had become trapped in the left ventricle by secondary cord attachment.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Apresentamos um caso de um homem, de 59 anos de idade, admitido no Serviço de Urgência por dor torácica e elevação ST nas derivações inferiores, r > s em V1 e depressão ST nas derivações precordiais, devido a oclusão da primeira obtusa marginal. Foi realizada angioplastia primária dessa lesão com implantação de <span class="elsevierStyleItalic">stent</span> revestido. Doze horas depois, o doente desenvolve instabilidade hemodinâmica, tendo sido diagnosticada uma insuficiência mitral grave por rutura de uma das cabeças do músculo papilar ântero-lateral. O doente foi submetido a cirurgia emergente (reimplantação do músculo papilar ântero-lateral, anuloplastia mitral com anel rígido, anuloplastia tricúspide e revascularização miocárdica). A inspeção cirúrgica revelou que a cabeça muscular rompida se mantinha presa ao ventrículo esquerdo por uma corda secundária que a ligava à outra cabeça do músculo papilar ântero-lateral.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Este caso tem a particularidade de apresentar 2 características incomuns da isquemia do músculo papilar: rutura do músculo ântero-lateral num enfarte póstero-inferior e o facto de a cabeça de músculo não prolapsar para a aurícula esquerda, por se encontrar presa ao ventrículo esquerdo por uma corda secundária.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0085" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 503 "Ancho" => 3000 "Tamanyo" => 121548 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram on admission demonstrating slight ST-segment elevation in the inferior leads, R<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>S in V1 and ST-segment depression in the anterior leads.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1065 "Ancho" => 1500 "Tamanyo" => 167645 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional transesophageal echocardiogram showing severe mitral regurgitation caused by posterior leaflet prolapse. LA: left atrium; LV: left ventricle.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1258 "Ancho" => 2500 "Tamanyo" => 176005 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional transesophageal echocardiography. (A) Full volume cropped image showing the detached head of the anterior papillary muscle inside the LV (arrow) causing severe prolapse of the posterior leaflet; (B) 3D Zoom of the mitral valve showing prolapse of the P1 and P2 segments. LA: left atrium; LV: left ventricle; Ao: aortic valve; LAA: left atrial appendage.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1072 "Ancho" => 900 "Tamanyo" => 104135 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Intraoperative view showing the forceps holding the detached muscle head. The two primary cords connecting the muscle head to the edge of the posterior leaflet are clearly seen.</p>" ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.avi" "ficheroTamanyo" => 5269504 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] 5 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.avi" "ficheroTamanyo" => 1412608 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] ] ] ] 6 => array:5 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.avi" "ficheroTamanyo" => 3227952 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Papillary muscle rupture complicating acute myocardial infarction: analysis of 17 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.A. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 10 | 5 | 15 |
| 2024 Outubro | 56 | 33 | 89 |
| 2024 Setembro | 70 | 32 | 102 |
| 2024 Agosto | 76 | 34 | 110 |
| 2024 Julho | 50 | 34 | 84 |
| 2024 Junho | 44 | 36 | 80 |
| 2024 Maio | 61 | 34 | 95 |
| 2024 Abril | 52 | 27 | 79 |
| 2024 Maro | 51 | 18 | 69 |
| 2024 Fevereiro | 40 | 19 | 59 |
| 2024 Janeiro | 42 | 29 | 71 |
| 2023 Dezembro | 36 | 21 | 57 |
| 2023 Novembro | 38 | 26 | 64 |
| 2023 Outubro | 29 | 14 | 43 |
| 2023 Setembro | 36 | 22 | 58 |
| 2023 Agosto | 50 | 14 | 64 |
| 2023 Julho | 30 | 8 | 38 |
| 2023 Junho | 49 | 13 | 62 |
| 2023 Maio | 46 | 27 | 73 |
| 2023 Abril | 24 | 2 | 26 |
| 2023 Maro | 32 | 19 | 51 |
| 2023 Fevereiro | 36 | 12 | 48 |
| 2023 Janeiro | 39 | 18 | 57 |
| 2022 Dezembro | 32 | 21 | 53 |
| 2022 Novembro | 49 | 21 | 70 |
| 2022 Outubro | 45 | 19 | 64 |
| 2022 Setembro | 42 | 29 | 71 |
| 2022 Agosto | 49 | 25 | 74 |
| 2022 Julho | 50 | 33 | 83 |
| 2022 Junho | 33 | 17 | 50 |
| 2022 Maio | 44 | 35 | 79 |
| 2022 Abril | 51 | 26 | 77 |
| 2022 Maro | 34 | 31 | 65 |
| 2022 Fevereiro | 56 | 16 | 72 |
| 2022 Janeiro | 29 | 27 | 56 |
| 2021 Dezembro | 32 | 29 | 61 |
| 2021 Novembro | 43 | 39 | 82 |
| 2021 Outubro | 48 | 39 | 87 |
| 2021 Setembro | 33 | 28 | 61 |
| 2021 Agosto | 55 | 30 | 85 |
| 2021 Julho | 27 | 24 | 51 |
| 2021 Junho | 29 | 12 | 41 |
| 2021 Maio | 35 | 21 | 56 |
| 2021 Abril | 39 | 33 | 72 |
| 2021 Maro | 75 | 21 | 96 |
| 2021 Fevereiro | 74 | 7 | 81 |
| 2021 Janeiro | 41 | 9 | 50 |
| 2020 Dezembro | 32 | 8 | 40 |
| 2020 Novembro | 36 | 13 | 49 |
| 2020 Outubro | 17 | 9 | 26 |
| 2020 Setembro | 58 | 8 | 66 |
| 2020 Agosto | 30 | 7 | 37 |
| 2020 Julho | 46 | 8 | 54 |
| 2020 Junho | 60 | 4 | 64 |
| 2020 Maio | 54 | 2 | 56 |
| 2020 Abril | 49 | 6 | 55 |
| 2020 Maro | 49 | 2 | 51 |
| 2020 Fevereiro | 108 | 37 | 145 |
| 2020 Janeiro | 46 | 8 | 54 |
| 2019 Dezembro | 49 | 5 | 54 |
| 2019 Novembro | 46 | 6 | 52 |
| 2019 Outubro | 68 | 3 | 71 |
| 2019 Setembro | 118 | 10 | 128 |
| 2019 Agosto | 79 | 4 | 83 |
| 2019 Julho | 61 | 9 | 70 |
| 2019 Junho | 84 | 9 | 93 |
| 2019 Maio | 74 | 8 | 82 |
| 2019 Abril | 86 | 10 | 96 |
| 2019 Maro | 128 | 10 | 138 |
| 2019 Fevereiro | 110 | 8 | 118 |
| 2019 Janeiro | 78 | 5 | 83 |
| 2018 Dezembro | 67 | 9 | 76 |
| 2018 Novembro | 122 | 6 | 128 |
| 2018 Outubro | 250 | 30 | 280 |
| 2018 Setembro | 61 | 9 | 70 |
| 2018 Agosto | 57 | 11 | 68 |
| 2018 Julho | 44 | 13 | 57 |
| 2018 Junho | 79 | 7 | 86 |
| 2018 Maio | 84 | 16 | 100 |
| 2018 Abril | 64 | 4 | 68 |
| 2018 Maro | 106 | 15 | 121 |
| 2018 Fevereiro | 52 | 3 | 55 |
| 2018 Janeiro | 72 | 3 | 75 |
| 2017 Dezembro | 71 | 10 | 81 |
| 2017 Novembro | 57 | 12 | 69 |
| 2017 Outubro | 43 | 8 | 51 |
| 2017 Setembro | 49 | 11 | 60 |
| 2017 Agosto | 53 | 13 | 66 |
| 2017 Julho | 44 | 10 | 54 |
| 2017 Junho | 50 | 9 | 59 |
| 2017 Maio | 55 | 16 | 71 |
| 2017 Abril | 38 | 6 | 44 |
| 2017 Maro | 30 | 13 | 43 |
| 2017 Fevereiro | 93 | 14 | 107 |
| 2017 Janeiro | 28 | 7 | 35 |
| 2016 Dezembro | 21 | 7 | 28 |
| 2016 Novembro | 31 | 14 | 45 |
| 2016 Outubro | 34 | 8 | 42 |
| 2016 Setembro | 39 | 11 | 50 |
| 2016 Agosto | 18 | 7 | 25 |
| 2016 Julho | 16 | 9 | 25 |
| 2016 Junho | 32 | 9 | 41 |
| 2016 Maio | 3 | 0 | 3 |
| 2016 Abril | 138 | 4 | 142 |
| 2016 Maro | 133 | 15 | 148 |
| 2016 Fevereiro | 142 | 19 | 161 |
| 2016 Janeiro | 137 | 9 | 146 |
| 2015 Dezembro | 144 | 11 | 155 |
| 2015 Novembro | 168 | 11 | 179 |
| 2015 Outubro | 172 | 12 | 184 |
| 2015 Setembro | 136 | 10 | 146 |
| 2015 Agosto | 165 | 19 | 184 |
| 2015 Julho | 177 | 8 | 185 |
| 2015 Junho | 118 | 6 | 124 |
| 2015 Maio | 154 | 11 | 165 |
| 2015 Abril | 160 | 12 | 172 |
| 2015 Maro | 172 | 11 | 183 |
| 2015 Fevereiro | 135 | 8 | 143 |
| 2015 Janeiro | 104 | 6 | 110 |
| 2014 Dezembro | 95 | 13 | 108 |
| 2014 Novembro | 114 | 10 | 124 |
| 2014 Outubro | 155 | 15 | 170 |
| 2014 Setembro | 166 | 11 | 177 |
| 2014 Agosto | 126 | 7 | 133 |
| 2014 Julho | 108 | 15 | 123 |
| 2014 Junho | 105 | 6 | 111 |
| 2014 Maio | 113 | 14 | 127 |
| 2014 Abril | 107 | 10 | 117 |
| 2014 Maro | 155 | 16 | 171 |
| 2014 Fevereiro | 156 | 13 | 169 |
| 2014 Janeiro | 153 | 19 | 172 |
| 2013 Dezembro | 136 | 8 | 144 |
| 2013 Novembro | 164 | 15 | 179 |
| 2013 Outubro | 114 | 20 | 134 |
| 2013 Setembro | 87 | 25 | 112 |
| 2013 Agosto | 90 | 26 | 116 |
| 2013 Julho | 95 | 27 | 122 |
| 2013 Junho | 92 | 14 | 106 |
| 2013 Maio | 87 | 40 | 127 |
| 2013 Abril | 134 | 52 | 186 |
| 2013 Maro | 43 | 26 | 69 |
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